Information form
To be filled in by the patient or their parents, and returned to the practice.
Tom Exemple
Rue de la Démonstration 1, 1000 Bruxelles
0400 00 00 00 · demonstration@exemple.be
The patient
| Surname | Simon |
| First name | Nathan |
| Date of birth | 29/06/2017 |
| National register number | 17.06.29-147.90 |
| Address | Rue de l'Exemple 1, 1000 Bruxelles |
| Phone | 0470 00 00 30 |
| E-mail | |
| Health insurance fund | Mutualité de démonstration Sud |
Contact persons (for a child: the parents)
Doctor, school, other professionals
| GP | |
| School and class | |
| Other professional | |
History
Reason for referral
Who refers the patient, why now.
Complaint and expectations
What the patient, the family or the school observe and expect.
Medical history
Pregnancy, birth, illnesses, operations, treatments.
Development
Motor skills, language (first words, first sentences), toilet training, sleep, eating.
Hearing and vision
Ear infections, grommets, audiogram, glasses.
Languages
Languages spoken at home and with whom; language of the school.
Schooling
School, class, repeating a year, adjustments, special education.
Follow-up
Previous speech therapy, other therapists, assessments already done.
Family background
Siblings, history of language or learning disorders.
Other information
Hobbies, interests, what motivates the patient.
Appointment reminders
I would like a reminder the day before each appointment:
by e-mail by SMS
This information is used for speech therapy follow-up and invoicing. It is kept by the practice, encrypted, and passed on to nobody without your agreement, except where required by law (health insurance fund, medical advisor). You can view it and have it corrected at any time.